Provider Demographics
NPI:1053400135
Name:LACABE-MOORE, WYNTRIA (MD)
Entity type:Individual
Prefix:
First Name:WYNTRIA
Middle Name:
Last Name:LACABE-MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 SUNSET TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-7793
Mailing Address - Country:US
Mailing Address - Phone:281-339-2916
Mailing Address - Fax:
Practice Address - Street 1:1403 HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4930
Practice Address - Country:US
Practice Address - Phone:832-260-0640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4259207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179352303Medicaid
TXP00459908OtherRAILROAD MEDICARE
TX8V1563OtherBCBSTX
TX8G2241Medicare PIN
TX8V1563OtherBCBSTX
TXP00459908OtherRAILROAD MEDICARE